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Psychiatric Drug Classes > Anxiolytics > Flashcards

Anxiolytics Flashcards

0
Q

What are the first-line agents (4) used for anxiety disorders?

A

Antidepressants such as SSRIs, duloxetine (Cymbalta), and Venlafaxine XR (Effexor XR)

Benzodiazepines

Buspirone (Buspar)

Hydroxyzine

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1
Q

What drugs are used to treat anxiety disorders?

A

Anxiolytics

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2
Q

What are the second line agents (2) used in the treatment of anxiety disorders?

A

Prazosin (Minipress)

Pregabalin (Lyrica)

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3
Q

What are the third line agents (4) that are used as alternative treatments for anxiety disorders that are primarily reserved for refractory cases due to concerns regarding safety and tolerability?

A

Antipsychotic agents– Minimal data supporting routine use; may be beneficial in refractory cases

Gabapentin (Neurontin)– Minimal data supporting its efficacy

Monoamine oxidase inhibitors

Tricyclic antidepressants

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4
Q

What is the mechanism of action for selective serotonin reuptake inhibitor’s?

A

They inhibit the reuptake of serotonin

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5
Q

What is the mechanism of action for duloxetine and venlafaxine?

A

They inhibit the reuptake of serotonin and norepinephrine

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6
Q

What is the mechanism of action for Buspirone?

A

It is a partial agonist at serotonin 1A receptors

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7
Q

What is the mechanism of action for hydroxyzine?

A

It is a histamine receptor antagonist

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8
Q

What is the mechanism of action of Prazosin?

A

It is an alpha-1 blocker primarily used in the treatment of hypertension

it may help nightmares and sleep disturbance in patients with PTSD

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9
Q

What is the mechanism of action of pregabalin?

A

It’s a calcium channel modulator inhibiting excitatory neurotransmitter release

It’s mechanism of action is very similar to gabapentin and structurally similar to GABA but does not act on benzodiazepine receptors

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10
Q

What are the 5 FDA approved indications for anxiolytic medications?

A

Generalized anxiety disorder

social phobia

panic disorder

posttraumatic stress disorder

obsessive-compulsive disorder

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11
Q

What is the non-FDA approved indication for prazosin?

A

It appears to be helpful for nightmares and sleep disturbance in patients with PTSD

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12
Q

What is the non-FDA approved indication for the use of pregabalin?

A

It has been largely studied in the treatment of general anxiety disorder

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13
Q

What is an adverse drug reaction more commonly observed with benzodiazepines such as diazepam, alprazolam and triazolam which have shorter half-lives, are used at higher doses, and are more lipophilic?

A

Anterograde amnesia – which is the short-term impairment of memory, and difficulty forming new memories

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14
Q

Can tolerance develop with long-term use of shorter half-life benzodiazepines such as diazepam, alprazolam, and triazolam?

A

Yes

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15
Q

Which adverse effect is associated with the use of duloxetine, hydroxyzine, and paroxetine?

A

Anti-cholinergic effects

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16
Q

What dose-related effect does duloxetine and venlafaxine XR exhibit?

A

Hypertension

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17
Q

What cardiovascular effect does prazosin exhibit?

A

Hypotension

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18
Q

What cardiovascular effect do the tricyclic antidepressants sometimes exhibit?

A

EKG changes, specifically QTC prolongation

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19
Q

Which class of medication can cause paradoxical excitation or disinhibition?

A

This may occur with benzodiazepines, especially among the very young and the very old; therefore, this may not be an ideal choice if patients are experiencing irritability, hostility and/or impulsivity

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20
Q

Benzodiazepines, duloxetine, hydroxyzine, paroxetine, and pregabalin share what side effect?

A

Sedation

21
Q

Benzodiazepines with a longer half-life, for example flurazepam, may cause patients to experience what type of effect?

A

A “hangover” effect – prolonged CNS effects into the next day

22
Q

Why should drugs that sedate be used cautiously in elderly patients?

A

If they have altered renal and/or hepatic function, this could result in elevated drug concentrations and an elevated fall risk

23
Q

Which class of medications can have a stimulating effect?

A

Serotonergic antidepressant agents, especially the SSRIs

24
Q

What are the 4 specific stimulating side effects seen with SSRI/serotonergic antidepressant agent use?

A

Insomnia, restlessness, agitation, and anxiety

25
Q

Why is it important to “start low and go slow” when using pharmacological treatment for anxiety disorders?

A

In general, patients with anxiety disorders are more sensitive to medication side effects, therefore, one should consider starting at half the usual starting dose for depression, and titrate more slowly

26
Q

As a result of the “start low and go slow” philosophy, what should a clinician expect over the course of treatment for patients with anxiety symptoms?

A

Due to the lower tolerability and slower titration schedule, full therapeutic benefits may be delayed. For example, it may take longer to see resolution of anxiety symptoms in comparison to depressive symptoms using the same agents

27
Q

True or false: the effective dose of the medication being used to treat anxiety symptoms may end up being higher than that used for the treatment of depression.

A

True

28
Q

Which 3 antidepressant agents are commonly associated with withdrawal symptoms? What is it due to? What specific symptoms (3) may be seen with missed doses or rapid tapers?

A

Venlafaxine XR, paroxetine and duloxetine

This is due to their short half-lives

Specifically, withdrawal symptoms may include insomnia, agitation, and anxiety with missed doses or rapid tapers

29
Q

Generally speaking, what are the two options that will help minimize the withdrawal effects of antidepressant medications?

A

Resume the previous dose and taper more slowly; or

Switch to a different serotonergic antidepressant with a longer half-life, (eg. Fluoxetine) and continue to taper

30
Q

Which type of benzodiazepines display withdrawal symptoms? What are three specific examples?

A

Agents with shorter half-lives

Lorazepam, alprazolam, or oxazepam

31
Q

The withdrawal symptoms seen with benzodiazepines may mimic what type of disorders? Which specific symptoms (4) may be seen?

A

It may mimic anxiety disorders; specifically, rebounding anxiety, insomnia, agitation, and dysphoria may be seen

32
Q

Which withdrawal symptom associated with benzodiazepine agents is most concerning?

A

Seizures

33
Q

When tapering doses of benzodiazepines, which stage is better tolerated, the earlier stages or the final stages?

A

The earlier stages are better tolerated

34
Q

Is there a specific time frame for tapering benzodiazepines?

A

No, there is no specific time frame, it should be largely based upon tolerability. However, a tapering schedule that is too long and drawn out (e.g., 6 months,) may also hinder a successful taper

35
Q

Does a slow taper of benzodiazepines eliminate withdrawal effects?

A

No, it only minimizes withdrawal effects

36
Q

When discontinuing benzodiazepines, what approach should be avoided?

A

Abrupt discontinuation

37
Q

Depending on how long the patient was receiving the benzodiazepine, the dose, the half-life, tolerability, etc., how should outpatients be tapered?

A

Reduce the dose by approximately 10-20%/week or slower

38
Q

What fact is important to remember when treating anxiety patients with serotonergic antidepressants?

A

Patients may mistake the stimulating effect of serotonergic antidepressants as a worsening of their illness, though these effects are often short-lived (lasting only days)

39
Q

What’s the best way to help patients avoid stimulating effects of antidepressants and improve compliance?

A

Consider starting patients at a lower dose (in comparison to the starting dose for depression). Although the target dose may sometimes be higher than those used in the treatment of depression, slow titration is recommended to minimize these effects

40
Q

To help patients avoid the stimulating effects of antidepressants and improve compliance, what other class of medications may be used during antidepressant initiation?

A

Benzodiazepines

41
Q

What class of medications are often used to “bridge” patients who are starting an antidepressant? Why?

A

Benzodiazepines; because the therapeutic effects of antidepressants are usually delayed for several weeks

42
Q

Benzodiazepines may be more effective than antidepressants for which specific anxiety disorder?

A

Social anxiety disorder

43
Q

Benzodiazepines may worsen symptoms in which type of patients (2)?

A

Social anxiety disorder with comorbid depression

PTSD

44
Q

Compare the onset of therapeutic activity between benzodiazepines vs. SSRI and SNRI antidepressants…

A

Benzodiazepines– Immediate

SSRI and SNRI antidepressants – delayed

45
Q

Compare the risk of stimulating\anxiety-like side effects of benzodiazepines vs. SSRI and SNRI antidepressants….

A

Benzodiazepines – absent

SSRI and SNRI antidepressants– Can occur, especially with higher doses, rapid titrations and certain SSRIs (e.g., fluoxetine)

46
Q

Compare the risk of dependence between benzodiazepines vs. SSRI and SNRI antidepressants…

A

Benzodiazepines – may occur, especially among patients with a history of substance abuse

SSRI and SNRI antidepressants– Absent

47
Q

Compare the risk of withdrawal-related side effects for benzodiazepines vs. SSRI and SNRI antidepressants…

A

Benzodiazepines may occur, especially with longer use, agents with shorter half-lives, and with a rapid taper or abrupt discontinuation

SSRI and SNRI antidepressants– May occur with duloxetine, paroxetine, or Venlafaxine (Shorter half-lives)

48
Q

Compare the risk of overdose with benzodiazepines vs. SSRI and SNRI antidepressants…

A

Benzodiazepines – it’s a risk, especially when taken with other CNS depressants, particularly alcohol

SSRI and SNRI antidepressants– Risk with tricyclic antidepressants: lethal QTC prolongation may occur

49
Q

Compare the sedative side effects of benzodiazepines vs. SSRI and SNRI antidepressants….

A

Benzodiazepines – yes, although tolerance may develop

SSRI and SNRI antidepressants– Yes, particularly among agents with high antihistamine activity (e.g. Paroxetine) tolerance often develops

50
Q

Compare the risk of cognitive impairment with benzodiazepines vs. SSRI and SNRI antidepressants….

A

Benzodiazepines – yes, especially with agents that are more lipophilic, with those with shorter half-lives, and at higher doses

SSRI and SNRI antidepressants– Possible with agents that have sedative and anti-cholinergic effects (e.g., paroxetine and duloxetine)

Psychiatric Drug Classes (10 decks)

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