Exam 2: Anxiolytics

Question 1

BZDs Place in anxiety therapy: Acute (4)

Answer 1

1. rapid relief needed
2. imitation of antidepressants
3. Generally NOT 1st line
4. MAX 6 weeks then taper dose
   - taper depends on drug, dose, duration

Question 2

BZDs place in anxiety therapy: long term use

Answer 2

reserved for severe, refractory anxiety cases

-refer to specialist!

Question 3

Antidepressants for anxiety: Follow-up (2)

Answer 3

1. every 1-2 weeks

2. monthly thereafter

Question 4

Antidepressants for anxiety: efficacy (2)

Answer 4

1. 4-6 week trial

2. remission/partial response/no response

Question 5

Antidepressants for anxiety: maintenance (2)

Answer 5

1. typically 12+ months at full dose

2. taper medication if no residual symptoms

Question 6

Antidepressants for anxiety: initial dosing (2)

Answer 6

1. start small
   - Rule of thumb: use hand initial antidepressant dose
2. patients often need higher doses for efficacy

Question 7

Buspirone

MOA
place in tx for anxiety 
dosing
Avoidance? 
Adverse Effects

Answer 7

1. MOA: partial agonist 5-HT1a receptor
2. 2nd line tx for GAD
   - FDA approved
   - monotherapy OR augmentation
3. 7.5 mg BID, up to 60mg today per day
   - delayed onset of effect: ~2 weeks
   - AVOID IN SEVERE HEPATIC/RENAL IMPAIRMENT
4. AE: dizziness, nausea, HA, akathisia (restlessness)

Question 8

Hydroxyzine Pamoate/hcl

MOA

Answer 8

block histaminic H-1 and serotonins 5-HT2 receptors, CNS depression

Question 9

Hydroxyzine Pamoate/ HCL

place in tx for anxiety

Answer 9

2nd line agent for GAD

• rapid effects: 15-30 minuts onset
• dose: 25-100mg up to 4x daily

Question 10

Hydroxyzine Pamoate/HC adverse effectsl (3)

Answer 10

1. CNS depression
2. anticholingeric effects
3. QTc prolongation

Question 11

Hydroxyzine Pamoate/HCL usefulness (3)

Answer 11

1. may be useful in abuse Hx
2. insomnia
3. pediatric anxiety

Question 12

Propranolol MOA

Answer 12

blocks cardiac beta receptor activation

1. decreases HR and force contraction
2. decreased BP
3. Dose ~ 40 mg IR about 1 hour prior to event

Question 13

Propranolol benefits

Answer 13

event-related anxiety

*off-label use

Question 14

Propranolol Adverse Effects (3)

Answer 14

1. low BP
2. fatigue
3. cold extremeties

Question 15

Pregabalin (2)

Answer 15

1. considered 1st line in some guidelines
   - some acute efficacy in GAD
2. not FDA approved

Question 16

Pregabalin dosing

Answer 16

1. 50 mg PO TID, up to 600 daily

2. dose adjustments required for CrCl < 60 ml/min

Question 17

Anticonvulsants

MOA

Answer 17

1. reduced neuronal excitability in fear circuits
2. similar to reduction in stimulation found in epilepsy

• small # supportive trials
• results mixed
• can be useful for augmentation in 1st line agents

Question 18

Antipsychotics for anxiety (3)

Answer 18

1. rx generally outweighs benefits
2. not approved for anxiety
3. second generation/atypicals can be considered severe, refractory d/o