Exam 4 Anxiety Flashcards
When do we treat anxiety?
-When it interferes with normal life
-When it interferes with part of another disease
What substances or actions can cause anxeity?
Caffeine
-Cell phone/Social Media withdrawal
Which neurotransmitters are involved in anxiety?
Norepinephrine (NE)
Serotonin
Corticotropin-Releasing Factor (CRF) and the HPA axis
How does Norepinephrine cause anxiety?
Over-active
*Projects to the amygdala (fear center)
What part of the brain is responsible for anxiety?
amygdala (fear center)
What is the role of GABA in anxiety?
-Normally counteracts the stimulatory effects of excess norepinephrine
*Hypothesis that reduced GABA signaling is responsible for anxiety
*Anxiolytics increase GABA signaling
What affect does GABA have (Inhibitory or Excitatory)?
Inhibitory
What effect does Glutamate have (Inhibitory or Excitatory)?
Excitatory
What converts glutamate to GABA?
Glutamic Acid Decarboxylase
(used in GAD)
What is the drug treatment used for anxiety?
-Benzodiazepines
-Antidepressants
-Buspirone
-Beta blockers
How fast do benzodiazepines work?
QUICK, effective
How fast do antidepressants work?
TAKE WEEKS
What is the new breakthrough antidepressant used for anxiety?
Ketamine
(nasal spray esketamine)
*Very quick acting
What is the MOA of Buspirone?
Partial agonist on brain 5HT 1A receptors
What is the adaptive response of Buspirone?
Has a longer onset of action than benzodiazepines
*Takes mush longer to work, not good for panic disorders
True or False: Buspirone has a low abuse potential
TRUE
-because it targets the 5HT 1A receptor
What is the beta blocker of choice for anxiety?
Propranolol (Inderal)
What do we need to be aware of when starting propranolol?
*May need initial test dose
(titrate so that patient is not put to sleep)
Relating to anxiety, what is propranolol especially good at treating?
Decreased peripheral symptoms of anxiety
What are promising investigational anxiolytics?
Glutamatergic agents
*glutamate is not targeted yet but being developed
What drugs cause anxiety?
-Albuterol
-Caffeine (high dose 800mg or more)
-Decongestants
-Levothyroxine
-Steroids
-Stimulants (ADHD) meds
What is Buspirone’s approved use?
Generalized Anxiety Disorder
What is the target dose of Buspirone?
10-15mg TID
(30-45 mg total/day)
How long does it take for Buspirone to be effective?
Up to 3-4 weeks
*patients often need higher doses to see effectiveness
What do treatment guidelines say about using benzodiazepines for anxiety?
-Many guidelines do not support their use in routine practice due to misuse potential
*But the effect size for efficacy in anxiety disorders is higher than serotonergic antidepressants in some studies
What is a limitation to using benzodiazepines?
Long-term use is not recommended
(dependence/tolerance risk)
True or False: Benzodiazepines cause withdrawal symptoms
TRUE
-can lead to life-threatening seizures
*requires slow taper off over weeks to months
What are the warnings associated with benzodiazepines?
Warning with concomitant use with other CNS depressants and overdose death risk
*specific warning for co-prescribing with opioids
Which benzodiazepines do not have an active metabolite?
Alprazolam
Lorazepam
Clonazepam
Oxazepam
**less likely to accumulate
**less fall risk
Which benzodiazepines have a long-acting active metabolite?
Diazepam
Clorazepate
Chlordiazepoxide
What are the side effects of benzodiazepines?
-Sedation
-Paradoxical excitement
-Swallowing difficulties
-Impairment of memory and recall
-Psychomotor impairment
Who should possibly not receive benzodiazepines?
Elderly
Which benzodiazepines are preferred in the elderly?
L-O-T
Lorazepam
Oxazepam
Temazepam
What is Hydroxyzine approved for?
GAD
How do you take hydroxyzine?
PRN
*for anxiety and insomnia
What are the side effects of hydroxyzine?
-Sedation
-Anticholinergic
*QTc prolongation
*Fall risk
Who should not receive hydroxyzine?
Elderly
(due to anticholinergic SE and fall risk)
What is propranolol used for?
Decreases the physiological symptoms associated with anxiety (tachycardia, sweating, flushing)
*Performance and Situational anxiety
What is the dosing of propranolol used?
*Low doses
*Used prn
What should be evaluated in patients to decide eligibility for propranolol?
-Evaluate for history/current asthma
-Evaluate for cardiovascular conditions
What are the natural products used for anxiety?
Kava
St. John’s Wort
Valerian
Passionflower
Chamomile
What side effects can Kava cause?
Hepatotoxicity + Liver failure
-Platelet aggravation
-Aggravates Parkinson’s symptoms
*use not recommended
What is the MOA of St. John’s Wort?
Strong 3A4 inducer
*watch drug interactions
Who should avoid taking valerian?
Pregnant women
When should passionflower be avoided and why?
Pregnancy
-due to risk of uterine stimulation and induction of early labor
Who should avoid chamomile?
*Patients taking blood thinners
*Patients with ragweed allergy
When should we consider gabapentinoids?
Patient with bipolar disorder who has anxiety or comorbid neuropathic pain
When should we consider quetiapine?
*Active metabolite theoretically has anti-anxiety properties
*Not something we really use
*Sleep medicine does not endorse its use for insomnia
What are the first-line options for anxiety disorders?
SSRIs
SNRIs
Buspirone
Which drugs are NOT approved for anxiety disorders but may be efficacious with treatment-resistant OCD?
Atypical antipsychotics
What is the definition of Generalized Anxiety Disorder?
Excessive anxiety/worry present for at least 6 months
Must include 3 of the following:
-Restlessness/Feeling keyed up or on edge
-Easily fatigued
-Difficulty concentrating or mind “going blank”
-Irritability
-Muscle tension
-Sleep disturbances
What is first-line maintenance treatment for GAD?
SSRI antidepressants
How long do SSRI’s take to work?
2-4 weeks
When are SNRIs first-line for GAD?
If patient also has a pain syndrome
How are benzodiazepines used for GAD?
“Bridge Therapy”
-covers time until SSRI/SNRI has effect
Which drug can be used prn for GAD?
Hydroxyzine
What is social anxiety disorder?
Persistent fear about social and/or performance situations in which the patient fears embarrassment or humiliation that is unreasonable
*patient may avoid situations and it can affect their routine
*DURATION OF SYMPTOMS AT LEAST 6 MONTHS
What is the first-line treatment for social anxiety disorder?
SSRI’s
When do we use beta-blockers with social anxiety disorder?
Non-generalized, performance-related SAD
What is Panic Disorder?
Recurrent, unexpected panic attacks
-Abrupt surge of intense fear or discomfort
*Includes both physical and psychological symptoms
*At least one attack has been followed by one month or more of at least one of the following:
—Persistent concern about additional attacks
–Significant maladaptive behavior change
What is first-line therapy for panic disorder?
SSRI’s
Which SNRI is FDA approved for panic disorder?
Venlafaxine
What drugs are first-line for OCD?
SSRIs
What % reduction in OCD symptoms can be expected?
25-50%
What drug is considered second-line for OCD?
Clomipramine
(if patient fails SSRIs)
What role do antipsychotics have in OCD?
*Are not FDA approved
*Augmentation therapy with SSRIs/SNRIs
Which antipsychotics have the best evidence for OCD use?
-Risperidone
-Aripiprazole
What is the first-line treatment for PTSD?
SSRIs/SNRIs
What can we use Prazosin for?
Can be helpful for sleep or nightmares with PTSD
What drug class is NOT recommended for PTSD?
Benzodiazepines
(they work but we do not use because of substance abuse)
What therapies can be helpful with PTSD?
Cognitive behavioral therapy
Eye movement desensitization and reprocessing
What symptom can occur when using SSRIs or SNRIs for anxiety?
Jitteriness
**initial doses should be lower than those used for depression
What are the mainstays of treatment for anxiety disorders?
Psychotherapy and Cognitive Behavioral Therapy
In which type of trauma may drug therapy be more useful in PTSD?
More effective in civilian trauma (one time event) than combat trauma
