lecture 62 Flashcards
ott - pharmacotherapy of anxiety disorders
what are drugs that can cause anxiety?
albuterol
caffeine (high doses)
decongestants
levothyroxine
steroids
stimulants (ADHD meds)
what are the CP related to buspirone?
5HT1a receptor agonist
approved for generalized anxiety disorder
may take up to 3-4 weeks for initial efficacy
should be dosed with a target of 10-15 mg TID
why are benzos not recommended for anxiety disorders?
not for routine practice due to misuse potential and acute withdrawal (which can lead to seizures that can be life threatening
what is the warning of benzos?
use with other CNS depressants due to overdose death risk
specific warnings for co-prescribing with opioids
what are SE of benzos?
sedation
paradoxical excitement
swallowing difficulties
impairment of memory and recall
psychomotor impairment
what benzos do not have an active metabolite?
alprazolam, lorazepam, clonazepam, and oxazepam
less likely to accumulate
fall risk associated
what benzos have an active metabolite?
diazepam
clorazepate
chlordiazepoxide
is long-acting
how should benzos be used in elderly?
may be inappropriate due to be on the Beer’s criteria
prefer L-O-T
what is hydroxyzine pamoate?
FDA-approved for the treatment of generalized anxiety – can also use HCl salt for lower 10 mg dose
use PRN for anxiety/insomnia instead of a benzo
what are the SE of hydroxyzine?
sedation and anticholingeric (avoid in elderly)
QTc prolongation risk
fall risk
how is propranolol used in anxiety disorders?
used for performance and situational anxiety in low doses
decrease physiological symptoms of acute anxiety (sweating)
evaluate for hx/current asthma and CV conditions
what is important to note about KAVA?
can cause hepatotoxicity and liver failure
what are CP of St. John’s Wort?
strong 3A4 inducer
mild MAO inhibitor
do not take with other antidepressants or serotonergic drugs due to SS risk
what natural proucts should be avoided in pregnancy?
valerian
passionflower (due to risk of uterine stimulation/early labor)
when should chamomile be avoided?
blood thinners
ragweed allergy
how are gabapentinoids considered in anxiety?
use in pts with BPD who have anxiety symptoms of comorbid neuropathic pain
can seroquel be used for insomnia?
no
not endorsed by sleep medicine despite having anxiolytic properties
what drug therapies are first line?
all anxiety disorders – SSRI/SNRIs
generalized anxiety disorders – buspirone
can atypical antipsychotics be used in anxiety disorders?
not FDA-approved but clinical evidence suggests efficacy for treatment-resistant OCD
aripiprazole and risperidone only
what qualifies as generalized anxiety disorder according to the DSM-5?
excessive anxiety/worry that is present for at least 6 months with at least 3 symptom criteria
what are the symptoms of generalized anxiety disorder that can help diagnose?
restlessness/feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind “going blank”
irritability
muscle tension
sleep disturbances
what treatments approved for GAD?
first-line SSRI (2-4 weeks needed)
useful –> SNRI antidepressants, buspirone, and hydroxyzine (PRN)
benzos for bridge therapy
how should benzos be used for GAD treatment?
used in bridge therapy to cover time until onset of SSRI/SNRI, where appropriate
must taper if pt has been taking long-term to avoid withdrawal
how is social anxiety disorder defined according to the DSM-5?
persistent fear about social and/or performance situations in which the pt fears embarrassment or humiliation that is unreasonable
symptoms for at least 5 months
specific situations may be avoided in a manner that interferes with pt’s normal routine
how is social anxiety disorder treated?
first-line –> SSRI
useful –> BB (for non-generalized, performance related)
how is panic disorder characterized by the DSM-5?
recurrent, unexpected panic attacks
at least one attack has been followed by one month or more of at least one of the following (persistent concerns or significant changes)
how is a panic attack defined?
abrupt surge of intense fear or discomfort
at least 4 physical or psychological symptoms, including sweating, palpitations, N, dizziness, fear of losing control, going crazy, or dying
how are panic disorders treated?
first line maintenance – SSRIs
useful –> Venlafaxine (SNRI), Benzo (if inadequate response to serotonergic drugs)
how is obsessive-compulsive disorders defined?
need both obsession (recurrent thoughts) and compulsions (repetitive behaviors)
how is OCD treated?
first line –> SSRI (with reduction of 25-50% of symptoms)
second line –> clomipramine (TCA)
Adjuct to SSRI/SNRIs –> antipsychotics (risperidone, aripiprazole)
how is PTSD defined according to the DSM-5?
exposure to real or threatened death, serious injury, or sexual violence (either victim, witness, discovery, exposure to details of traumatic event)
can experience flashbacks, re-exerpeincing, avoidance, hypervigilance, or negative alterations in mood or cognition
how is PTSD treated?
first-line –> SSRI/SNRIs (only classes FDA-approved)
helpful –> prazosin (sleep/nightmares)
non-recommended –> benzos
what are common associations with treatment of PTSD?
polytherapy common
SUD is common
CBT and eye movement desensitization/reprocessing can be helpful
what is jitteriness syndrome?
can result from use of SSRI/SNRIs when treating anxiety disorders
initial dose should be lower than doses used for depression to minimize this SE
what is the onset of action for SSRI/SNRIs?
2-4 weeks
what are the non-pharm treatments of anxiety disorders?
psychotherapy and CBT
in what type of PTSD is drug therapy prefered?
in civilian trauma (usually a one-time event)
combat trauma usually requires non-drug treatment
